Like many Emergency Departments, Memorial Health has been working to reduce waiting times. Recently, they have successfully reduced the wait time for a CT scan by 30%, which has reduced length of stay, avoided a capital expenditure cost, and improved throughput in their Level I Trauma Center. This was achieved at Memorial Health by integrating process simulation into their standard Six Sigma DMAIC projects. Todd Roberts shared with us the details of their approach to process improvement, of which simulation is a key component. - Analyze – Built and validated the model. - Improve – Identified bottlenecks and tested process changes. - Control – Used results to predict sustained outcomes. Learn how Memorial Health achieved this remarkable improvement in service and sustained the results.

1. Memorial Health System:
30% Reduction in Wait Times
Using DMAIC
Todd S. Roberts, MBA, CLSSMBB
Administrator, Quality and Safety
Memorial Health System

2. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
1 800 547 6024 | +44 141 552 6888
Presenters
Todd S. Roberts
Administrator, Quality and Safety
Memorial Health System
roberts.todd@mhsil.com
Brittany Hagedorn
SIMUL8 Healthcare Lead, North America
LEED AP
SIMUL8 Corporation
brittany.h@SIMUL8.com

3. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
1 800 547 6024 | +44 141 552 6888
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5. Systems thinking is the ability to see
things as a whole (or holistically),
including the many different types of
relationships between the diverse
elements of a complex system
Necessary component of “learning
organizations”
Takes cause-and-effect thinking to a
higher level and encourages the user
to see not just the linear causal
connections but also the web of
causal interconnections that come
into play in real systems
“The Fifth Discipline”

6. “Adjusting the system or process
inputs to produce the best possible
average response with minimum
variability”
System Optimization

7. The sensitive
dependence on initial
conditions, where a
small change at one
place can result in
large differences to a
later state.
Butterfly Effect

8. Three types of failures in complex systems:
– Procedural
• Failure to adhere to/execute a defined process
• Single, obvious mistakes
• Special-cause variation
• Plan, Do, Check, Act or corrective action
– Engineered
• People, process, materials
• Common-cause variation
• Defined processes
• Lean Six Sigma projects
– System
• Complex interactions between processes and risk factors
• Difficult to understand and pinpoint cause and effect relationships
• Discrete event simulation
Failure in Complex Systems

9. The Emergency Department CT machine experiences high volumes with at times high
amounts of back up causing delays in patient care. In the past the ED CT department has
used several experimental initiatives such as: additional tech assistants and doing patient
work-ups ahead of time. The department was no longer able to work up patients ahead of
time, as the needed staff were no longer available. Prior process work was done, showing
the benefit of having an extra FTE, however request were unsuccessful.
The ED CT Department has been frontloaded with moving towards more CT exams without
oral contrast.
There is additional project work showing more lab test for fewer CT tests, in order to rule
out DVT
Stroke and Trauma services compete for CT services
When the ED CT scanner is backed up, the patient flow process moves patients up to the
Medical Imaging first floor CT machine.
Emergency Department Case Study
Background

10. DEFINE MEASURE ANALYZE IMPROVE CONTROL

11. Wait times for patients causes delays in patient
care. This causes an increase in anxiety for the
patient, a delay in receiving a definitive diagnosis,
as well as a delay in the treatment plan.
Press Ganey 30th Percentile for ED Radiology
Wait Times
ED CT machine is the most used in the system
Lost Revenue
Business Case

12. • ED CT Department
• TAT CT Exam ordered vs.
Started
OUT OF SCOPE
• MMC 1st floor CT
• Baylis CT
• Dictation process
• TAT Results Received vs.
Discharge Time
Project Scope
IN SCOPE

13. Insert your process map here

14. Project Charter
Problem Statement: The Emergency Department CT machine is the busiest in the health
system, however the delays in ED CT Throughput of patients creates cost on the
organization, decreases staff satisfaction, creates quality concerns, and decreases patient
satisfaction with increased patient wait times averaging an hour from ordered to started.
Who is/are the customer(s): Patients, Ordering Clinician, Medical Imaging, Families, MHS,
Radiologists, Nurses, Emergency Department
What is the Cost of Poor Quality (COPQ): Harm and pain to patients, delay in treatments plans
for patients, waste of machine/room usage, nursing time with patients
What is Critical to Customer Satisfaction (CTS) or Critical to Quality (CTQ): Timely Efficient
Patient Centered
Current Project Y: CT completed in Emergency Department in a timely manner
Project Y Specification: Start CT Exam in ED within 45 minutes of being ordered
Project Y Metric: TAT CT Started vs. CT Ordered
Defect Definition: CT Exam starting > 45 minutes from being ordered
Project Objective: Reduce TAT from CT Exam ordered versus CT Exam Started
Unit Definition: CT Exam in ED
Baseline Zst: 2.0 Baseline DPMO: 539,125

15. DEFINE MEASURE ANALYZE IMPROVE CONTROLMEASURE

16. Focus

17. CT Paged to TA Sent- 40:31 minutes
TA Sent to Patient Arrival- 5:05 minutes
Patient Arrival to Landmarked- 3:57
minutes
Total Average time from Paged to Scan
Occurring- 49:33 Minutes
15 of the 38 cases observed, patient was
not ready
Is the Patient Ready for CT Exam?

18. DEFINE MEASURE ANALYZE IMPROVE CONTROLANALYZE

19. Why are ED Staff paging that a Patient is
ready?
• ED Staff assume patient is prepped accordingly and
labs are complete and that the patient is ready for CT.
What do they believe this?
• The pre-labs are ordered and staff believe they are
complete.
Why do they believe they are complete?
• Because no one in the ED is validating that the labs are
or are not complete before the CT Exam.
Why is no one validating that the labs are not
complete?
• The resources needed to do so, are not present or
available in the department.
5 Whys Analysis

20. Patients are not ready for their CT in the ED
upon page because the needed resources
are not available to validate that the patient is
ready.
Point of Care testing, this includes both
creatinine and pregnancy testing, is not taken
advantage of on the patients that require pre-
CT Lab testing (CT with Contrast).
Critical Inputs

21. Micro problem Statement
CT Exams performed in the ED require a patient to be
properly prepped and ready for their exam. Patient needs to
have the proper IV in place, dressed appropriately, restroom
used, jewelry off, consents complete, and the required pre-CT
labs complete. When this is not complete it causes a delay in
patient care with increased patient wait time, averaging an
hour from ordered to start. These delays can be attributed to
lack of resources in order to validate the patient is ready for
the exam and Point of Care testing not being taken advantage
of in the ED.

22. Determine whether the implementation of
an additional technician assistant will
improve CT turnaround time
ED Simulation Goals

23. Compared both a day and a week elapse
Based on ED CT Data for May, June, and
July
Compares Current State with 1 CT Tech
Assistant vs. 2 CT Tech Assistants
Based on time CT is ordered vs. CT started
Simulation Model

24. Queuing Model Results
Current State
1 Day Elapse

25. Queuing Model Results
Extra Tech Assistant
73% have CT within 30 minutes of order
27% reduction
in longest time a
patient waits
1 Days Elapse

26. Queuing Model Results
Current State
1 week elapse

27. Queuing Model Results
Extra Tech Assistant
33% reduction in
longest time a
patient waits
82% Patients are having CTs within 36
minutes of order
1 Week Elapse

28. DEFINE MEASURE ANALYZE IMPROVE CONTROLIMPROVE

29. New CT Tech Asst Process
CT Tech Assistant
• 7 days a week, 11:00-7:30
• 1.5 FTEs
• Patient Prep
• Jewelry
• Clothing
• Communication of Delays
• Consent forms
• Screening forms
• Confirmation of labs
• Transports Pt to ED Scanner
• Transports Pt to main MI if
needed
• Communicates with ED Staff

30. CT TA Intervention Results
UCL 3:40:39
3:20:11
CL 1:36:49
1:10:36
0:00:00
1:12:00
2:24:00
3:36:00
4:48:00
1
10
19
28
37
46
55
64
73
82
91
100
109
118
127
136
145
154
163
172
181
190
199
208
217
226
235
244
253
262
271
280
289
298
307
316
325
334
343
352
361
OrderedVs.StartTAT
Patient Enounter
ED CT Tech Asst. Results
Comparison Hours 11:00-19:30
27%
Reduction in
Wait Time
Baseline Z Score= 2.0 Pilot Z Score 3.49

31. Requires deep process understanding (avoid
tampering)
Creates a shared visual understanding of the process
for all parties
Allows for observational analysis and modification
without physical intervention in a complex environment
(offline trial and error)
Supports improved decision-making through
management by fact
Discrete Event Simulation Benefits

32. House-wide patient placement (PACU, ED,
direct admits, etc.)
Pharmacy IV compounding production
ED intake process (critical access hospital)
System (hospital) CT utilization optimization
Emergency department “pod” structure
ED admission handoff process
Current Projects

33. Contact: roberts.todd@mhsil.com
(217) 757-7782

34. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
1 800 547 6024 | +44 141 552 6888
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